Contraceptives newer : New arrivals

 

Denial of contraceptive choices to Indian couples: Contraceptive basket is 1/4^th full for Indian coupe of reproductive age !!!  What are the newer contraceptives which are licensed abroad but not approved to import neither to manufacture at India by Drug controller of India   ?? There is a  long list of 40 such newer contraceptives which are used in many countries. I don’t like to  mention contraceptives which are in trail phase also called as contraceptives-in-horizon, Such are 1) vaginal microbicidal often called Invisible condom2)  trial on Proneem 3) Tet  toxoid which will  produce antibodies against LH, 4)  say Wax plugs in either vas –biodegradable.

 

 .However let me mention about 35 temporary methods which are reasonably popular abroad but not available in India . I have told you about monthly combined Oestrogen & progesterone inj (Lunelle) , Besides, following are the list :  1) Frame less IUCD  2) CuT- mixed with Indomethacin, 3) Copper T IUCD mixed with alloy like gold/ silver 4) Gynae fix -T Cu-Fix 5  ) Copper T IUCD mixed Mefanamic acid 6)  Other materials impregnated in Cu  Devices,6) other Prostaglandins impregnated Cu T devices 7) Cervical IUCDs, 8) string less IUCDs A) Male condoms varieties in shape , texture, colour, scent, with/ without out tip such are   1) Spring condom 2) Glow-in-dark Male condoms 3) Different flavored/ colored / scented / tasty condoms 4) Lamb skin male condom Baggy condoms 5) Glow in dark condoms   6) Extra strength condoms     7) SPRING CONDOM    8) Panty condom –for women to be fitted as and when emergency situation arises
9) Unisex condoms 10) Multi colour banded condoms and 11) ,Male condom covering the glans only and many more ..

 A) Newer implants :-specially newer Biodegradable sub dermal implants(Brand name anule) , and newer progesterone containg implants  

Coming to vaginal barriers there are about 12 newer Female  controlled methods some of which may be used or fitted covertly without the knowledge of partner visiting to toilet prior to sex and fitting the cervical cap/ diaphragm  at toilet. But  not all such devices can be hided e.g. Female condoms which covers labia & perineum from STD Newer female controlled methods are  1) Leas Shield as barrier method, 2) ,Reddy Female condom, 3)PATH condom 4) FC female condom  Nestorone vaginal ring (Progesterone only vaginal Ring –also called VCRà implying vaginal  contraceptive Rings) 4)Lily diaphragm, 5) Oves Cap, 6) Ortho coil spring 7) Today sponge with 1000mg Nonoxynol vaginal sponge  8) practiced  vaginal sponge

N F P:- Self monitoring of Ovulation by electronic monitor: Trade Bioself ovulation monitor,LadyComp.

 

 All are waiting for approval at India for last one decade !!!1 Minimal contraceptive options for Indian couples. !!!1

Tuberculosis of female genital Tract what options we have now??

 

Q.1: In which diseases  PCR technology is used ?? Ans:  PCR technology is extensively used in analysing clinical specimens for the presence of infectious agents, including 1) HIV, 2) hepatitis,3)  human papillomavirus ., 4) Epstein-Barr virus (glandular fever), 5) malaria and 6) anthrax. Tuberculosis is a disease caused by the bacteria Mycobacterium tuberculosis that generally attacks the lungs however possibly can affect other parts of the body. Genital tuberculosis (GTB) is a potent contributor to irreversible damage to the reproductive system and infertility in females.

Female GTB of the endometrium is a well-recognized entity in the etiology of infertility, especially in TB endemic countries like India.

Q.2: Advantages of PCR technology?? Ans: The diagnosis is a challenge to the clinician as it is mostly either asymptomatic or presents with nonspecific symptoms in affected females.It could be observed through this study that 65% of the cases of infertility were due to the tuberculous involvement of endometrium. Schaefer and Onuigbo in their two different reports have shown an involvement of ET in 50%–60% of the case  of FGB.

 TB PCR is a rapid and reliable test in the diagnosis and management of tuberculosis. The TB-PCR is one of the tests that helps diagnose and confirm an infection of Tuberculosis.  The hsp65 Nested PCR of MB can be used as a noninvasive screening test for early diagnosis of GTB.

. Q.3: How there is subfertility due to genital Kochs?? Ans:  Infertility might,  be occurring due to disturbed implantation of the developing embryo on the endometrium.

Early reproductive age is the most vulnerable period to acquire GTB. This could be because of the fact that after puberty the blood supply to the pelvic organs is increased resulting in more bacilli reaching and seeded in the reproductive organs. Many researchers have studied this aspect of female GTB comparing different diagnostic tests on ET and MB samples .Correct diagnosis often relies on ET sample obtained by biopsy which is an invasive procedure. But by contrast menst blood(MB)  as a sample in the detection of endometrial TB has been used in many studies, but its utility over the endometrial sample in detecting infection is still a subject to explore.

 

 Q,. 4: So as on date , dilemma exists about which method is accurate so far exact diagnois Is made with certainty. Therefore as no gold standard diagnostic tool is yet available, clinical suspicion and relatively insensitive approaches such as A) histopathology, B)  laparoscopy and C) hysterosalpingogram are currently critical determinants in the diagnosis of GTB.

Although a polymerase chain reaction (PCR)-based assay using endometrial tissue seems promising, sampling does require an invasive procedure.

 

Point 5: Points in favour of PCR dependent diag in contrast to histology or Culture??The sensitivity and specificity of PCR were 93%  and 84%, respectively. HIV status did not affect the sensitivity of PCR. A total of 99.7% of the true smear-positive and 82.1% of the true smear-negative TB patients were correctly identified by PCR.

Using Bactec 360 culture as the gold standard, the overall sensitivity of TB PCR was 78.3%, and for pulmonary and extrapulmonary specimens it was 82.3% and 72.0%, respectively. However, mycobacterial culture, which has the highest sensitivity for diagnosing and confirming active TB, requires 2 to 6 weeks for interpretation Conclusions: TB PCR is a rapid and reliable test in the diagnosis and management of tuberculosis. Using culture as the gold standard, the overall sensitivity of TB PCR was 78.3%, and for pulmonary and extrapulmonary specimens it was 82.3% and 72.0%, respectively.: 

The traditional less sensitive, time-consuming, and labor-intensive methods, i.e., histopathalogical and mycobacteriological examinations (smear and culture) in the diagnosis of TB are now been overshadowed by more sensitive, rapid, and easier PCR-based methods. Researchers have recommended direct molecular detection of MTC be used as an adjunct to other methods of laboratory diagnosis of TB,

The specificity (82.9%) and sensitivity (72.3%) of the detection of MTB from MB samples have been reported by various authors . Few studies have reported the sensitivity range between 55% and 90% of the detection of MTB by PCR from clinical specimens.

The limitations of the PCR techniques are the false-negative results (more common with MB samples ) which can be attributed to either paucibacillary nature, or inefficient extraction of the DNA from the sample. Thus, sampling plays an important role in the accuracy of detection of GTB.

 

Since the involvement of the genital tract in TB could be generalized or patchy, and the technique of sample collection is blind, there is a possibility of missing the infected area when ET is collected. However, the overall positivity rate of MB can be increased by repeated sampling over a period of time. While multiple sampling for ET (invasive method) is not feasible, a noninvasive sample like MB which can be taken during different cycles and extracting DNA from a large volume of MB for PCR seems to be a better specimen in these circumstances. An added advantage of MB sample is that the MB can be collected undertaking sterile precautions by the patient itself from the periphery and can be sent to the laboratory for further workup.

Our study is unique as we have assessed the utility of nested PCR on MB over ET samples collected from the same patient. None of the studies conducted so far have made a similar comparison to the best of our knowledge. Nested PCR using MB as a sample has an insignificant difference with that of ET. Thus, MB seems to have a practical utility in being a noninvasive test and could be used as a preliminary screening test for diagnosis of GTB. On the contrary, Q.8: What isnew method of diag of genital Kochs?? Ans :Patil et al. in their study did not find MB to be a potential alternative clinical sample in the diagnosis of endometrial TB. They had MB as well as endometrial aspirates tested by a commercial kit GEN-PROBE AMPLIFIED M. tuberculosis direct test which is a nucleic acid amplification test..

Proper counselling on Breast feeding= Imparting its contraceptive efficacy should be considered as method of contraception-A novel patriotic duty

 Counsel the couple with confidence. Lactation amenorrhoea Method: What we as obstetricians need to know enabling us to counsel the couple efficiently in clear language ?? Ans: LAM is surprisingly is the most common method of contraception in the first six months after childbirth. Believe me or not. Scientists have recently designated this form of family planning as ‘Lactation Amenorrhoea Method’ or L.A.M. It is the use of breastfeeding as a temporary family planning method. LAM provides natural protection against pregnancy and encourages starting another method at the proper time. Not all lactating women are protected against pregnancy and only following group of women are protected against pregnancy during breastfeeding period i.e.

a) Her baby gets at least 85% of his or her feedings as breast milk, and she breastfeeds her baby often, both day and night AND
b) Her menstrual periods have not returned since childbirth AND lastly,
c) Her baby is less than six months old.
All these three criteria should be fulfilled to achieve near 100% contraceptive effect of breastfeeding. If a women keeps breastfeeding very often, her protection from pregnancy may last even longer than stipulated six months and perhaps as long as nine to twelve months after last childbirth. This is called extended use of LAM. Knowingly or unknowingly this extended L.A.M. i.e. natural contraception beyond six months is often availed by Indian rural women. This is a form of natural family planning and costs nothing. Our nation thus avoids several thousand unwanted births annually by adopting extended LAM method. In this context it may be pertinent to mention that a mother should ideally breastfeed up to two years along with weaning at six months followed by supplementary foods (partial breastfeeding).

Detailed criteria of LAM
As stated earlier to make breastfeeding as a successful method of natural contraception the woman concerned has to follow all the following criteria e.g.
1. She should breastfeed at least six times during day time and at least one preferably two feeds at night without supplementing water or any other drink. This is what is called exclusive breastfeeding. Author wonders how many urban women will take the trouble to put her baby to breast two or three times in night. LAM to be cent percent effective total feeding duration i.e. suckling time in twenty four hours should be ideally above eighty minutes or more.
2. As soon as menstruation resumes after childbirth she should commence some form of contraception because it is well known that contraceptive efficacy of LAM is markedly reduced as menstruation resumes after childbirth.
3. The contraceptive efficacy fades but not markedly reduce six month after childbirth in spite of continued breastfeeding. Thus six month age of infant is a landmark for initiation of contraceptive even if menstruation do not resume.
Efficacy of LAM as contraceptive
LAM method of contraception is about ninety eight effective in preventing conception in first six months postpartum provided the concerned woman remains amenorrhoeic (nonoccurrence of menstruation). Failure rate of LAM is up to two pregnancies per 100 women in the first six months postpartum even if no supplementary food is added to baby during this period i.e. strict adherence to the policy of exclusive breastfeeding. Nevertheless, two percent failure rate is not uncommon with other contraceptives too and no couple should raise their eyebrow on this minimal failure rate.

Advantages of adopting LAM as Contraceptive:
1. Effectively prevents pregnancy for at least first six months and this the period of coverage may be longer if a woman keeps breastfeeding often, day and night.
2. Encourages the mother to adopt standard breastfeeding patterns thus indirectly improves health of infant. The couple and relatives should remember that breast milk provides the healthiest food for the baby.
3. No direct cost for family planning.
4. No question of contraceptive related side effects.
5. No need to do anything at time of sexual intercourse.
6. Protects the baby from life-threatening diarrhea and protects the baby from other infectious diseases such as measles and pneumonia (respiratory tract infections) by transmitting the mother’s immunities to the baby through breast milk. In Indian context breast milk provides a natural and highly effective panacea against fatal diarrhea of neonates and infants.

Disadvantages of LAM method of contraception:
1. Effectiveness after six months is uncertain.
2. The words ‘exclusive breastfeeding’ sounds simple but it requires considerable effort and dedication on the part the woman. Frequent breastfeeding, though ideal may be inconvenient or impractical for some women, especially working mothers.
3. Unlike condoms, there is no protection against sexually transmitted Infections (STIs) including HIV/AIDS. Thus if a woman is infected with HIV and if her partner does not use condom during sexual intercourse she may transmit the HIV through such unprotected sex. So ideally partners of all HIV positive women should use barrier methods of contraception during sexual intercourse though women can use female condom or newer cervical barrier devices which will be equally effective in prevention of STI. Breast milk also can transmit HIV virus to neonate though such chance again is little. Such transmission of virus through breast milk is also applicable for Hepatitis B virus which is also secreted in milk.

Limitation of breastfeeding as contraceptive:
Though, breastfeeding is an important and effective means of child spacing, still some uncertainty exists about the extent to which a woman can rely on lactation induced suppression of ovulation for contraception. This is because feeding practice varies from women to women. When compared to oral contraceptives or sterilization, breastfeeding may not be that effective form of contraception, since women may occasionally resume ovulation within six months of childbirth while still breastfeeding as per norms. It all depends on how frequently the baby is put to breast and above all the total duration of breastfeeding per twenty four hours. It is needless to mention that these two factors have great individual variations. What are more important, day to day variations may occur due to maternal or infant illness or for social or religions grounds. Thus if a woman fails to breastfeed as per norms for couple of days for above quoted valid reasons then ovulation can ensure prematurely. All these factors pose a problem in judging initiation of additional contraceptive in an individual woman. Therefore, there is a need of individualization in timing of initiation of contraceptives during breastfeeding period which is at times difficult.
As stated earlier during lactation amenorrhoea the probability of pregnancy for first six months is initially low i.e. 2%. But chance of pregnancy increases after six months even if the woman concerned remains amenorrhoic ,e nonoccurence of menstruation). All Breastfeeding women should remember that once she regains her menstrual pattern, contraceptive reliability induced by breastfeeding decreases rapidly and hence other means of contraception are always advisable. This applies particularly when the baby is being weaned and solid foods are gradually introduced. As stated, in rural India partial breastfeeding may continue for many months which offers some protection from pregnancy but not hundred percent.

Breast feeding and Contraception

 As a sensible Father in Law or Mother in Law : your duty is impart contraceptive knowledge to your daughter in Law /own daughter. An appeal by Prof S K Pal to juniors (and teachers as well) : Never be happy with the status quo of our practice at antenatal OPD. Over the last two decades we have trying to hammer on D marker NT scan, Q serum marker, TIFA, Foetal Echo as deem necessary and Tdap similarly we have to hammer this topic of LAM at antenatal OPD to every pregnant women however busy / crowded that place may be . May please entrust this task to PHN/ Social posted at antenatal OPD(ANC) & to your private secretary at private chamber. May also pl make a printed instruction on this LAM Method in detail in local language.

: The contribution of lactation amenorrhoea to birth spacing should be categorically disseminated to mothers especially during the prenatal visits. Basic information on ideal breastfeeding practice should also be communicated to family members, in laws, and opinion leaders in the commmunity.
The following globally accepted practice should repeatedly be communicated while the mother is still in hospital or nursing home these are a) exclusively breastfeeding for first six months, with frequent suckling on demand, both day and night. b) Continuation of breastfeeding even after supplemental foods has been introduced after 6 months. C) The most appropriate time for introducing other family planning methods should be established, for each individual based mainly on breastfeeding patterns and trends, and obviously on the duration of lactation amenorrhoea. The couple should also be made aware of the available fertility regulating methods, for lactating women. The couple should preferably use nonhormonal methods of contraception e.g. IUD (Intra-uterine devices) or condom. In the authors opinion these two are ideal contraceptives from four to six months postpartum.
But those breastfeeding women who desire hormonal contraceptive protection they can choose progesterone only hormonal contraceptives e.g. minipill or Inj. Progesterone i.e. quarterly shots. This hormonal method also has a track record good efficacy and safety. If none of these four methods are selected the combined oral contraceptives may be started only after six months of childbirth as it adversely affects quality of breast milk (WHO category 2 risk so long baby is breastfeeding).
However to initiate and promote breastfeeding important of personal support is very relevant. Personal contact and support really helps breastfeeding to succeed. This may be from health workers, counselors, family members, or from other breastfeeding mothers in the community. Radio broadcasts, newspaper articles and lectures can increase people’s knowledge, but they may not change what mothers do. Person-to-person help is necessary to convince mothers to put the ideas into practice.

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Bellagio Consensus on L.A.M. of Contraception: not on probability of ovulation and selection of drug dosage in ovulation induction?

 

Bellagio Consensus on L.A.M. of Contraception:

      In 1988 a group of reproductive scientists from all over the world met in Bellagio, Italy. They proposed that postpartum women could use lactation amenorrhoea method as a means of family planning. It is these experts who first unambiguously disclosed that women who are fully or nearly fully breastfeeding and amenorrhoeic are likely to experience a risk pregnancy at the rate of less than two percent in the first six months after childbirth. This consensus later came to be known as ‘Bellagio Consensus’. This method of natural contraception, very rightly was soon widely accepted in many countries. The principle of Bellagio consensus as a standard method of natural family planning was reaffirmed by another meeting at Bellagio in 1989 and this consensus was renamed as ‘Lactation Amenorrhoea Method (LAM)’ of contraception.

      Incidentally, it may be recalled that International consensus conference on Medical abortion i.e. nonsurgical method of abortion was also held at Bellagio city, Italy, 1-5^th November 2004 under the auspices of World Health Organization, Rockefeller Foundation and a NGO (IPAS). Thus Bellagio city is dedicated to reproductive rights and reproductive freedom of woman!

      After Bellagio consensus an International guidelines on ‘Breastfeeding and LAM’ were framed in 1989 and these guidelines were widely circulated in different countries. These guidelines included all three previous standard criteria, all of which must be fulfilled to ensure adequate protection from an unplanned pregnancy i.e. a) amenorrhoea, b) full or nearly full breastfeeding, c) first six months postpartum. The newly issued guidelines however included one additional warning for lactating women. The warning is that if any women who no longer meet all these three criteria, or no longer wish to use LAM, should immediately initiate use of additional family planning method if she intends to avoid pregnancy. It means partial breastfeeding does not offer cent percent protection from pregnancy. The guideline however had another clear message. That is it is the suckling stimulus that results both amenorrhoea and associated protection from pregnancy due to an anovulation (nonrelease  of eggs). Hence, adding supplements to the infant’s diet or decreasing the duration of breastfeeding below sixty minutes per twenty four hours and therefore  decreasing total suckling period may hasten the return of ovulation and shorten the efficacy of LAM.

What opinion Bellagio consensus encompasses on extended use of LAM ?

As an Indian we would be interested to know the effect of extended breastfeeding on contraception i.e. if breastfeeding is continued beyond six months. Many women in rural India breastfeed up to four or five years. What opinion the said experts expressed on breastfeeding-induced natural contraception in such cases? Are they as immune to pregnancy as is enjoyed in first six months? Certainly not. Let us now see what experts say on this issue which is so relevant in Indian context.

Experts opine that it may be possible to extend LAM beyond six months and there is nothing wrong in this age old practice. But so far as contraceptive effect is concerned their argument was that infants older than six months definitely need some supplemental feeding to maintain their health and development. Naturally, supplementation with other foods decreases breastfeeding frequency considerably. This by reducing suckling duration can result in release of eggs from ovaries. The experts also warned that in such cases ovulation and mistimed pregnancy can follow even if she remains amenorrhoeic. As such, women who continue to breastfeed beyond six months despite supplementation, (that is the usual scenario in rural India) the rate of pregnancy during ‘lactation amenorrhoea’ will be higher than that of first six months postpartum. Pregnancy rate however, remains low, than those women who do not breastfed at all. This is called ‘extended use of LAM’.

      Many studies on LAM were conducted since Bellagio consensus. Experts again gathered at Bellagio on 4^th Dec, 1995 and they collectively reviewed all the study reports which were available from different countries. The committee concluded that the Bellagio consensus of 1989 was worthy and appropriate including ‘extended use of LAM.’ Sporadic studies conducted thereafter (1996-2008) to assess the validity of Bellagio consensus have reaffirmed that women who are fully or nearly fully breastfeeding are at very low risk of becoming pregnant in the first six months postpartum or as long as they remain amenorrhoeic.

How can we motivate Indian mothers to accept scientific breastfeeding practices?

There is urgent need to educate all pregnant women (would -be -mothers) about standard breastfeeding practices. Family members and community leaders should also be communicated about benefits of exclusive breastfeeding and other healthy breastfeeding practices. Doctors and health care providers too need updating of their counseling skills on breastfeeding by attending workshops and seminars on this issue. Their noble duty is to part all these scientific knowledge i.e. ‘Dos’ and ‘NOT to dos’ to would be mothers during prenatal visits and also during discharge from hospital or nursing home after childbirth.

a)         Who is responsible for wrong breastfeeding practices? Readers will be shocked to know the results of one Indian survey. This recent study disclosed that of the mothers who decided for early formula feeding 46% were motivated by the suggestions received from family members and neighbors and in 43% such women the decision to start a formula feed was influenced by the doctors and health workers! What an unfortunate scenario! In rest 11% women who started formula feed too early were influenced by different media and advertisements.

b)        We can do better: Tips to promote breastfeeding: Breastfeeding and family planning are mutually reinforcing components of any health policy. Many of us understand that early discontinuation of breastfeeding presents considerable health hazards to infant. But we seldom understand that acceptance of standard breastfeeding practice not only benefits the concerned infant but also increase the birth interval by inducing lactation amenorrhoea. Lactation anovulation associated with amenorrhoea resulting from exclusive breastfeeding represents an important child-spacing mechanism in many third world countries. This is because frequent stimulation of the nipple during breastfeeding produce prolactin hormone which in turn reduces some hormones called pituitary ( a gland located in  brain )(pituitary gonadotrophins). It is this prolactin hormone which causes inhibition of menstruation of egg release. For more details of mechanism of an ovulation interested readers may consult vol-II ‘Breastfeeding and Child spacing’ written by the author.

Contraception by LAM method-Lactation Amenorrhoea Method

 

 

Q.& Ans on LAM

Principle:    In women using Lactation Amenorhoea Method (LAM) and exclusive breast-feeding the chance of pregnancy in the first six months after childbirth is very low (2%). Still if there is apprehension about conception EC (emergency contraceptive ) may be used if one is worried ,There is no harm in such emergency contraceptive.  Use of emergency contraceptive may be used as and when warranted in lactation period as such pills  do not affect milk production and can be safely used.

 Q 1: .  What is meant by Lactation Amenorrhoea Method of Contraception (LAM)?

Ans. Most of us have heard this term earlier but no teacher have explained to us properly. By LAM it is meant natural temporary infecundity enjoyed by a woman in the first six months following childbirth provided. But three conditions do apply .Such are :-

Condition 1:  She has not resumed menstruation after childbirth –

Condition 2:  She is putting the infant to breast at least 80 minutes per twenty four hours. This mean she is breastfeeding every 3-4 hours including one or two breastfeed at night breastfeed at night. This will ensure an ovulation (no release of eggs from ovaries) and thus prevent conception.

Condition 3 :  This LAM method is not applicable after six completed months of childbirth.

 Q.2 : All right. The action of LAM is over after six months. Then what??

Ans:  Sadly , in spite of informations and availability of different methods of dependable contraceptives which can be safely used during breastfeeding period in a planned and phased  way six months post childbirth  few couple uses such regular dependable contraceptive methods as per international norms.

 Q. 3: What is their back of mind?? Why couple don’t use  dependable safe reversible contraceptives post delivery after six months  more so in rural areas of India?? Ans: Many couple  engages in unprotected sex during this special period (after six months and more so if she is amenorrhoic after Last child birth) assuming that pregnancy cannot occur so long as infant is breast feeding !!! Unfortunately this is far from true and ovulation can resume after six months even if she is breast feeding (including exclusive) and has remained amenorrhoic.  

Q. 5? Here come role of emergency contraceptives in a big way,  It is noteworthy that these new types of drugs emergency contraceptives(EC) can prevent pregnancy not only from unprotected coitus but also prevent pregnancy if there is a contraceptive accident (see below—omission of COC, POP, Unknowingly expulsion of Cu T device, delay in Inj DMPA over 96 hrs) ).

These Kind of drugs emergency contraceptives are sometimes called as “morning after pills”, last chance contraceptives, after sex contraceptives. But they are better named emergency contraceptives. Such type of drugs is safe for breastfeeding women  and women should have no doubt on this. The only limitation of these drugs is that such drugs don’t protect against sexually transmitted diseases.

   

 

Doppler studies of different foeatl arteries and veins and how best to detect hypoxaemia earliest ??

 

Antenatal Foetal wellbeing by Doppler study!!! To whom to trust?? Is it arterial Doppler changes (Umbilical artery, MCA  changes ) or venous Doppler changes ( Umbilical  veins, ,Ductus venosus  & Tricuspid flow ) Point 1:-How many of members believe that “a decrease in the cerebral placental Doppler ratio provides an early and sensitive marker of redistribution of cardiac output which often precedes overt growth delay by up to 2 weeks.

Point 2 :-What is the sequence of changes due to hypoxemia of foetus :-The reduction of fetal growth velocity usually but not always mirrors in the following order  A) elevation in umbilical artery blood flow resistance and is   B)  followed by decreasing middle cerebral artery impedance.

 

Point 3: We shouldn’t make a hurried decision as soon as   umb artery undergoes some adverse changes!!!  We should keep in mind that Fetal Doppler assessment that is based on the umbilical artery alone is no longer appropriate particularly in the setting of early onset IUGR prior to 34 weeks.

 

 POINT 4:  Then how we should assess foetal condition and be assured about health of foetus?? Ans:  Incorporation of middle cerebral artery and venous Doppler provide the best prediction of acid base status, risk of stillbirth and the anticipated rate of progression.

Point 5: Whenà there will be foetal hypoxemia but a normal pH. Ans:-In growth restricted fetuses with an elevated Doppler index in the umbilical artery , with Doppler evidence  of brain sparing in MCA  with the presence of normal venous Doppler parameters(like Ductus)  is typically associated with hypoxemia but a normal pH.

 

Point 6:-How much relevant is venous  Doppler of Umb venous flow ? :à Yes. The abnormal venous Doppler parameters, including that of Umb veins are the strongest Doppler predictors of stillbirth. Reasons are even among fetuses with severe arterial Doppler abnormalities the risk of stillbirth is largely confined only to those fetuses that haves abnormal venous Doppler’s.

 

But Venous Doppler findings of DV that are particularly ominous are 1) absence of flow changes  or 2) reversal of the ductus venous 3) “ a”  wave and  & 4)  biphasic /triphasic umbilical venous pulsations.

 

In such settings there is a risk of a 25% stillbirth. But when the study is limited to preterm severe IUGR population these Doppler findings have a 65% predictive sensitivity and 95% specificity, when fetal compromise is  accelerated there is a further steady rise in umbilical blood flow resistance venous Doppler indices escalate  over a wide range

 

Point 7: Oligohydramnios and metabolic academia is characteristics of  ineffective downstream delivery of cardiac dilatation with whole systolic tricuspid insufficiency complete fetal inactivity , short term variation below 3.5 m/sec and spontaneous cardiac late decelerations of the fetal heart rate can be observed as preterminal events.

 

 

 

 

How placental dysfunction is is reflected in Doppler indices?? Ans:- As diagnostic tools 1) elevated umbilical artery blood flow resistance 2) and /or middle cerebral artery brain sparing provide evidence of placental dysfunction.

In the fetal compartment elevation of the umbilical artery Doppler index is observed when approximately 30% of the fetal villous vessels are abnormal.

 

What does “Absence or even reversal of umbilical artery end diastolic velocity: warns us in an whispering voice?? Ans:- Such changes may  occur when 60% to 70% of the villous vascular tree is damaged. Therefore, the benefit of umbilical artery Doppler , umbilical artery Doppler , when used in conjunction with standard antepartum testing was associated with a decrease  of up to 38% in perinatal mortality antenatal admissions, inductions of labor and cesarean deliveries for fetal distress in labor in women considered at high risk.

What other in formations we receive from Umbilical vessels??  Ans:-Development of umbilical venous pulsations in fetuses with absent end diastolic velocities in the umbilical artery was associated with a fivefold increase in mortality. Researchers have demonstrated that gestational age at the onset maternal hypertension and the development of pulsations in the umbilical venous velocities were significantly correlated with the interval of time between diagnosis and delivery for late decelerations for the FHR.

In summary Doppler evaluation of the umbilical cerebral and precordial vessels (if possible) in  the growth restricted fetus informs us :->1)  important diagnostic and prognostic information of in utero foetus. Fetal academia and the risk of stillbirth are high with progressive elevation of venous Doppler indices.

 

Risk factor based Screening protocols : Not only Doppler studies but other methods of foetal surveillance should also be used to achieve maximum information about foetal oxygenation and hypoxemia .

Advancing Doppler abnormalities indicates acceleration of disease and requires increased frequency of fetal monitoring. In growth restricted fetuses, Doppler evaluation is complementary to all other surveillance modalities.